Failure to Provide Adequate Supervision and Accident Hazard Prevention Resulting in Multiple Resident Falls
Penalty
Summary
The facility failed to ensure adequate supervision and accident hazard prevention for three residents with a history of falls, resulting in repeated incidents and injuries. One resident with a history of cerebrovascular accident and limited mobility experienced three unwitnessed falls over a three-month period, including one that resulted in a major injury—a cortical fracture of the left femoral greater tuberosity. Despite care plan updates requiring staff assistance, use of a walker, and implementation of 15-minute safety checks, there was no documentation of these checks being completed, and no physician orders were found for the interventions. The resident was not listed on the CNA report sheet for 15-minute checks, and staff interviews confirmed a lack of documentation and inconsistent implementation of fall prevention measures. Another resident with dementia and poor balance had multiple unwitnessed falls, including incidents where required safety interventions such as anti-slip mats and gripper socks were not consistently included in the care plan or documented as being used. After a fall resulting in a suspected fracture, the care plan was updated to require line-of-sight supervision when out of the room and 15-minute checks while in bed, but again, there was no documentation that these interventions were consistently performed. Staff interviews revealed that 15-minute checks were not documented, and care plan updates were not always reflected in practice. A third resident with dementia and a high risk for falls experienced four falls, including one that resulted in a right hip fracture requiring surgical intervention. The care plan was updated to include 15-minute safety checks and supervision during transfers, but there was no documentation of these checks being completed. The facility's fall prevention strategy relied on updating care plans and increasing safety checks, but lacked consistent documentation and follow-through. Interviews with facility leadership confirmed that interventions such as bed and chair alarms were not used, and that the QAPI committee was not actively addressing fall prevention at the time of the survey.